Common use of Requirements for Care Management Clause in Contracts

Requirements for Care Management. Demonstration Plans will offer Care Management services to all Enrollees based on their risk-level to ensure effective linkages and coordination between the medical home and other providers and services and to coordinate the full range of medical and social supports, as needed, both within and outside the Demonstration Plan. All Enrollees will be assigned a Care Coordinator and a care team. As stated in section c(ii) above, Enrollees shall be assigned to one of three levels – low, moderate, or high-risk. The intensity of Care Management services will depend on an Enrollee’s risk level. For Enrollees stratified as low-risk, Demonstration Plans will provide prevention and wellness messaging and condition-specific education materials. For Enrollees stratified as moderate-risk, Demonstration Plans will provide Care Management services dedicated to problem-solving interventions. For Enrollees stratified as high-risk, Demonstration Plans will provide intensive Care Management. The State and CMS will monitor Demonstration Plans’ performance throughout the operation of the Demonstration and will require that Plans have the capacity to perform the full range of Care Management activities, health assessments, and care planning. i. Requirements for an Interdisciplinary Care Team (care team) – Every Enrollee must have access to and input in the development of an interdisciplinary care team led by a Care Coordinator. The care team will be person-centered: built on the Enrollee’s specific preferences and needs and with his or her input, delivering services with transparency, individualization, respect, linguistic and Cultural Competence, and dignity. Care teams will: 1. Be led by a Care Coordinator who is accountable for coordination of all benefits and services the Enrollee may need. Care Coordinators will have prescribed caseload limits that vary based on risk-level (see section d(iv)). Where the Care Coordinator is not also the service coordinator, the service coordinator will be incorporated into the care team; 2. Support providers in medical homes, assist in assuring integration of services and coordination of care across the spectrum of the healthcare system, and help provide Care Management for Enrollees; 3. Assure appropriate and efficient care transitions including discharge planning; 4. Assess the physical, social, and behavioral risks and needs of each Enrollee; 5. Provide medication management; 6. Provide Enrollee health education on complex clinical conditions and wellness programs; 7. Assure integration of primary, specialty, behavioral health, LTSS, and referrals to community-based resources, as appropriate; 8. Maintain frequent contact with the Enrollee through various methods including face-to-face visits, email, and telephone options, as appropriate to the Enrollee’s needs and risk-level. For Enrollees stratified to high-risk, a member of the care team must engage in face-to-face contact with the Enrollee at least once every 90 days or as specified in the HCBS waiver if more frequent and applicable; and 9. Assist in the development of a person-centered Care Plan within 90 days after enrollment; and 10. Assist in the implementation and monitoring of the person- centered Care Plan.

Requirements for Care Management. Demonstration Plans MMIPs at minimum will offer Care Management services to all Enrollees based on their risk-level tier level, needs and preferences to ensure effective linkages and coordination between the medical home medical, behavioral health, LTSS, and other community providers and services and to coordinate the full range of medical and social supports, as needed, both within and outside the Demonstration PlanMMIP. All Enrollees will be assigned a Care Manager or Intensive Care Coordinator and a care team. As stated in section c(ii) above, Enrollees shall be assigned will have access to one of three levels – low, moderate, or high-riskan Interdisciplinary Care Team (ICT). The intensity of Care Management services will depend on an Enrolleethe beneficiary’s risk tier level. . a. Care Management for Tier Level One Enrollees: For Enrollees beneficiaries stratified as lowTier One, MMIPs will have a designated Care Manager, have an ICP, have access to an ICT, and receive referral assistance when applicable. MMIPs will be required to provide the full range of care coordination, including connecting beneficiaries with local community services, and coordinating referrals for other non-riskCovered Services, Demonstration Plans such as supportive housing and other social services, to maximize opportunities for independence in the community. b. Care Management for Tier Level Two Enrollees: For beneficiaries stratified as Level Two, MMIPs will provide Care Management services dedicated to problem-solving interventions, have an ICP, provide prevention and wellness messaging and condition-specific education materials, and provide access to an ICT. MMIPs will be required to provide the full range of care coordination, including HCBS waiver service planning when applicable, connecting beneficiaries with local community services, and coordinating referrals for other non-Covered Services, such as supportive housing and other social services, to maximize opportunities for independence in the community. c. Intensive Care Management for Tier Level Three Enrollees: For Enrollees stratified as moderate-riskLevel Three, Demonstration Plans MMIPs will be required to provide Intensive Care Management services dedicated to problem-solving interventions. For Enrollees stratified as high-riskprovided by an Intensive Care Coordinator, Demonstration Plans will provide intensive Care Management. The State and CMS will monitor Demonstration Plans’ performance throughout the operation of the Demonstration and will require that Plans have the capacity to perform the full range of Care Management activities, health assessmentsan ICP, and care planning. i. Requirements for an Interdisciplinary Care Team (care team) – Every Enrollee must have access to and input in the development of an interdisciplinary care team led by a Care Coordinator. The care team will be person-centered: built on the Enrollee’s specific preferences and needs and with his or her input, delivering services with transparency, individualization, respect, linguistic and Cultural Competence, and dignity. Care teams will: 1. Be led by a Care Coordinator who is accountable for coordination of all benefits and services the Enrollee may need. Care Coordinators will have prescribed caseload limits that vary based on risk-level (see section d(iv)). Where the Care Coordinator is not also the service coordinator, the service coordinator will be incorporated into the care team; 2. Support providers in medical homes, assist in assuring integration of services and coordination of care across the spectrum of the healthcare system, and help provide ICT Intensive Care Management for Enrollees; 3. Assure appropriate and efficient care transitions including discharge planning; 4. Assess the physical, social, and behavioral risks and needs of each Enrollee; 5. Provide medication management; 6. Provide Enrollee health education on complex clinical conditions and wellness programs; 7. Assure integration of primary, specialty, behavioral health, LTSS, and referrals to community-based resources, as appropriate; 8. Maintain frequent contact with the Enrollee through various methods including which supports “high touch” Intensive Care Management that uses face-to-face visitsinteractions to build essential trusting relationships that will xxxxxx beneficiaries to effectively communicate their needs, emailexpectations, and telephone optionsstrategies to meet their self- defined health goals. MMIPs will be required to provide the full range of care coordination, including HCBS waiver service planning when applicable, connecting beneficiaries with local community services, and coordinating referrals for other non-Covered Services, such as appropriate supportive housing and other social services, to the Enrollee’s needs and risk-level. For Enrollees stratified to high-risk, a member of the care team must engage in face-to-face contact with the Enrollee at least once every 90 days or as specified maximize opportunities for independence in the HCBS waiver if more frequent and applicable; and 9. Assist in the development of a person-centered Care Plan within 90 days after enrollment; and 10. Assist in the implementation and monitoring of the person- centered Care Plancommunity.